Podcast
Questions and Answers
What is the definition of confidentiality in healthcare?
What is the definition of confidentiality in healthcare?
- Sharing information with healthcare professionals
- Keeping information private (correct)
- Sharing patient information with family members
- Recording patient data accurately
What is a characteristic of accurate documentation?
What is a characteristic of accurate documentation?
- Recording observations taken by other healthcare professionals
- Omitting dates and times from records
- Using illegible handwriting
- Only charting observations taken by you (correct)
What is the primary purpose of written communication in healthcare?
What is the primary purpose of written communication in healthcare?
- To ensure reimbursement for services
- To provide a permanent record of patient information and care (correct)
- To educate healthcare professionals
- To conduct research studies
What is the purpose of using abbreviations in documentation?
What is the purpose of using abbreviations in documentation?
What is a key consideration in written communication for enrolled nurses?
What is a key consideration in written communication for enrolled nurses?
What is the primary focus of objective documentation?
What is the primary focus of objective documentation?
What is the purpose of a patient's admission form?
What is the purpose of a patient's admission form?
What is a benefit of accurate and complete written records?
What is a benefit of accurate and complete written records?
What is the main characteristic of timely documentation?
What is the main characteristic of timely documentation?
What type of documentation note records relevant patient and nursing activities throughout a shift or during a single visit?
What type of documentation note records relevant patient and nursing activities throughout a shift or during a single visit?
What is a purpose of a patient's health record?
What is a purpose of a patient's health record?
What does the 'P' in PIE documentation stand for?
What does the 'P' in PIE documentation stand for?
What is essential for effective written communication in healthcare?
What is essential for effective written communication in healthcare?
What is the purpose of a handoff during a shift change?
What is the purpose of a handoff during a shift change?
What is a fundamental aspect of written communication in healthcare?
What is a fundamental aspect of written communication in healthcare?
What is a purpose of a patient's graphic sheets and flow sheets?
What is a purpose of a patient's graphic sheets and flow sheets?
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Study Notes
Written and Oral Presentation Skills
- Importance of written skills for enrolled nurses: written communication serves as a permanent record of patient information and care.
- Written communication involves:
- Documentation and reporting
- Adherence to confidentiality
- Consideration to clients' basic human dignity
- Accurate and complete record
- Accessible to healthcare team
- Ensures continuity of care
- Provides essential data for revision or continuation of care
Patient Records
- Types of patient records:
- Admission form
- Nursing Care Plan
- Progress Notes
- Graphic sheets and flow sheets
- Medical history and examination
- Diagnostic tests results
- Consent forms
- Discharge forms
- Referral forms
Purpose of Health Record
- Legal document
- Communication
- Assessment
- Care Planning
- Quality Assurance
- Reimbursement
- Research
- Education
Principles of Documentation
- Confidentiality: keeping information private
- Accurate:
- Only chart observation taken by you
- Date and time
- Legible
- Use correct spelling
- Complete:
- Nursing process
- Complete information to be obtained and recorded
- Concise:
- Use abbreviations approved by the hospital
- Objective:
- Record actual behavior of patient
- Organized:
- Record all nursing care provided
- Logical and systemic grouping of important information
- Timely:
- Document all nursing care provided in timely manner
- Legible
- Writing must be clear
- Record numbers clearly
Documentation Notes
- Narrative:
- Recording relevant patient and nursing activities
- Write time and date of entry
- Identify person's role
- Activities carried out
- SOAP:
- S-subjective data
- O-objective data
- A-assessment
- P-plan
- Pie:
- P-problem
- I-intervention
- E-evaluation
- Focus (DAR):
- D-data
- A-action
- R-response
- Flow sheets
- Charting by exception (CBE)
- Clinical pathways
Oral Presentation
- Verbal communication
- Change of shift Handoff
- Importance of effective handoff in inpatient settings
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